The Western Sydney University, School of Medicine (SoM) is a five year undergraduate programme, established in 2007. The first 2 preclinical years are founded on problem based learning and students spend one day a week in the hospitals gaining clinical experience. For the final 3 years of the course students are immersed in urban, rural and community clinical placements. Personal and Professional Development (PPD) is one of four themes that structure the curriculum. The PPD theme focuses on the social, cultural and ethical dimensions of medicine to facilitate the development of students’ professional identity. PPD is a recent curricular requirement for medical school accreditation, which has arisen in response to public concern about the medical profession’s increasing focus on technical expertise at the expense of a moral commitment to patient centred care.¹²

The SoM was established, rather expeditiously, as part of a comprehensive government response to significant patient safety concerns at the local hospitals in one of most disadvantaged areas of Sydney.¹³ Commencing with few staff and insufficient time to develop a home grown curriculum, the foundation curriculum was imported from an interstate medical school. During the inaugural years, student feedback about the PPD curriculum of the first 2 preclinical years was highly critical. PPD was denigrated as ‘soft’ and worse ‘useless.’ The negative discourse around PPD was noted by the national accreditation body for medical education during an early visit to the School, creating a strong impetus for curriculum reform.

Curriculum development requires clarity about educational outcomes, the foundation on which content, instructional design, assessment and evaluation is established.¹⁴ The foundational curriculum lacked a clear conception of professionalism on which to base the PPD goals and outcomes. Developing that vision through scholarly inquiry and engagement with faculty members was a critical task.^15,16

The traditional conception of professionalism as a list of individual traits and mutable attributes is underpinned by the assumption that identity formation is primarily an intrapersonal process.¹⁷ This discourse remains dominant in medical education with an accompanying pedagogical focus on the development of appropriate values and attitudes¹⁶ and the corresponding need to identify those students who exhibit problematic behaviour.¹⁷ However, an emphasis on individual responsibility can result in a punitive approach to professionalism, thereby missing the opportunity to develop a curriculum which focuses positively on the personal development of every student.¹⁸ Moreover, this discourse ignores the negative effects of the hidden curriculum^3,16 which include the erosion of empathy⁷ and rise in cynicism in medical students.¹⁹

Medical education requires discourses of professionalism which explain the hidden curriculum, to enable students to identify and resist its negative impacts.^17,20,21 The discourse of professionalism as an interpersonal process considers that identity is formed and enacted in relationships with others thereby illuminating the critical impact of hierarchical relationships on professionalism. Individual attributes remain important; however they are not fixed but mutable and co-created between people.¹⁷

The discourse of professionalism as a societal and institutional phenomenon, the most recent discourse to emerge in the literature, explains professional identity formation as a result of socialisation into a particular context.¹⁷ Professionalism cannot be understood apart from the social, cultural and political forces that operate within, and on, the healthcare system.^20-22 Curriculum that intends to prepare students to participate in professional practice must move beyond the prevailing individual view to adopt a more complex construct of professionalism in which all three discourses operate and intersect in sometimes contradictory ways.^{17, 20, 21}

This conclusion has implications for the pedagogical theories on which curriculum renewal and development should be based. Learning theories which focus on personal cognitive and behavioural processes are inadequate to guide curriculum founded on a conception of professional identity as a social process.^17,20-22 Increasingly, educators and researchers have adopted sociocultural theories, such as Lave and Wenger’s Community of Practice (CoP), to illuminate the importance of socialisation for professional identity development.²³ However, Lave and Wenger’s theory is insufficient to guide curriculum development because it reveals, but does not challenge the negative ramifications of the hidden curriculum.^24-26

Lave and Wenger’s theory, based on the concept of CoP, explains learning as increased participation in the social and cultural practices of a community which consists of members who share a common activity and purpose.^{27, 28} Learners develop their professional identity through a process of socialisation into a new social language which involves learning to ‘walk the walk’ and ‘talk the talk’.^{22, 29, 30} Identity confirmation based on the need for social recognition is the motivating force that drives individuals to increase their participation in communities of which they are a member.³¹ Communities of practice explain how the hidden curriculum operates and reveals why the medical profession reproduces itself so successfully.^{25, 26}

Lave and Wenger are philosophically committed to education as a mutual development process in which communities and learners influence each other; learning as a process of transformation not reproduction.²⁷ However they do not clearly describe the processes which would enable novices to recognise or navigate problematic aspects of the dominant culture of communities of practice.^25,26 Medical educators committed to transformative education face a dilemma; participation in communities of practice is critical for professional identity formation, but risks conformity to the dominating discourse. To navigate this paradox we draw on more radical pedagogy which aims for social change.

Mezirow’s theory of transformative learning aims to empower students to resist the negative effects of the hidden curriculum by promoting critical thinking.³² Mezirow argues that education should not only focus on instrumental learning, but must also challenge students to see the world from different perspectives which he calls, communicative learning.³² Communicative learning involves a critical questioning of the goals, values and norms of the communities of practice which are taken for granted. This type of learning requires engaging students in critical reflection, a process of questioning the validity of the premises of personal meaning perspectives which have been tacitly acquired, to reveal inaccurate assumptions that may be epistemic, sociocultural or psychic.³²

Transformative learning is risky, and intellectually and emotionally challenging for teachers and students.³³ Teachers require a philosophical commitment to the aims of transformative learning and an ability to engage students in exploring different ways of knowing.^32,34 Their role is to create a safe and non-hierarchical learning environment to foster the development of peer dialogue and supportive relationships, critical for the success of transformative learning.³⁵ 

Committed to curriculum development which aims to support students to develop a patient-centred professional identity, we utilised both Lave and Wenger’s and Mezirow’s learning theories to guide the redevelopment of the preclinical PPD curriculum. Lave and Wenger’s theory emphasises the importance of belonging and social recognition for professional identity formation; the positive and necessary components of enculturation.³⁶ Medical education must aim to transform students into ‘the sort of person’ who does the kind of work that doctors do in the real world.²⁹ Medical students need to develop a professional identity which necessitates them feeling that they are part of the profession.^29,37 However, aiming to assuage the negative effects of enculturation, we also drew on Mezirow’s transformative learning theory to promote students to critically question the norms and values which shape the medical profession whose membership they seek.

We adopted design based research (DBR) methodology for our inquiry into theory led development of the PPD curriculum. DBR is an iterative approach to research embedded in practice; and encompasses phases of analysis and exploration, design and construction and evaluation and reflection.^38,39 DBR shares the assumption common to both Lave and Wenger’s CoP and Mezirow’s transformative learning theories, that students cannot be understood separate from their learning context. The implication for educational research is that theory and practice cannot be considered separately; theory and practice are dialectically related. Therefore this methodology supports our dual and integrated aims of local practice improvement through action informed by theory and conversely, theory development through reflection on action in practice.⁴⁰

Curriculum design and implementation is highly contextually dependant⁴¹ necessitating analysis which extends beyond the learner to encompass the sociocultural context. Therefore, we used Activity Theory (AT) which takes the whole complex learning environment as the unit of analysis, to guide our inquiry. Consistent with our research methodology and pedagogical approach to curriculum development, AT conceptualises learning, not as an accumulation of  discrete knowledge and skills but a process of transformation and identity construction as students develop their role/s in relation to the goals of a learning community.⁴²

The founding principle of AT is the cultural mediation of individual action. Learning emerges from participation in collaborative purposeful activities, mediated by cultural tools, symbols and signs which fundamentally shape psychological development. This concept is represented by the AT triangle demonstrating the dialectic relationships between the subject (the learner), the object (the purpose of the activity) and the tools (mediators of learning) which may be either conceptual or technological.⁴³

Acknowledging that the individual cannot be considered separately from the community of which they are a member, Engestrom extended the AT model to include the interacting and interdependent elements of community and the rules and division of labour which govern and mediate individual and collective action.⁴³ Sites of contradictions and instability within and between activity systems represent historically accumulated structural tensions which can be targeted for educational interventions to facilitate learning.⁴³

We used Activity Theory as a tool to identify and analyse the contradictions in the foundational PPD learning environment that were contributing to the negative discourse. The next version of the PPD curriculum was designed to address these structural tensions and to facilitate student learning towards the renewed curricular aims and objectives. After two years of implementation, another cycle of evaluation and analysis was performed to evaluate students’ attitudes to the reformed ‘soft’ professionalism component of the medical curriculum.

Ethical approval from the Human Research Ethics Committee of Western Sydney University was obtained for this study (research protocol, H9980). We invited all students from the first two years of the course and their PPD tutors to participate. All ten PPD tutors agreed to participate in a focus group discussion. From a cohort of 238 students across years 1 and 2, 212 students completed the surveys, a response rate of 89%. The average age of the year 1 and 2 cohorts was 21, and there was an even gender distribution in both years. 

During each of the two analytical cycles of the research project, multiple sources of data were obtained to populate the AT model and inform the analysis. For the first evaluative phase, the learning guides and materials, and curriculum and assessment documents were analysed, the results of routine quantitative university student evaluation surveys reviewed, and informal interviews with students and teachers undertaken. During the second evaluative phase data were obtained from a qualitative, free text response survey undertaken by students and focus group discussion with the tutors (refer to Table 1 for survey and focus group questions).

The surveys were completed anonymously and no identifying data were sought or collected. Two focus groups were conducted so that all tutors (n=10) could participate on at least one occasion. Two facilitators (GM and SW) used semi-structured⁴⁴ open-ended questions to explore sites of tension in the PPD learning environment. The two facilitators had no academic responsibilities for the PPD theme but were members of the Medical Education Unit. The digital recordings were transcribed (by VL and GM) into written text for analysis.

A thematic analysis was undertaken (VL and GM) of both the student and tutor qualitative data. The data from the year 1 and 2 student cohorts were initially analysed separately, however, because of the congruence of responses, the data were combined for final analysis. The data analysis was commenced individually and then developed into a collaborative process which involved comparing data, themes and more integrative analysis of meaning, back and forth, until shared understandings were achieved.⁴⁴ The next step involved presenting and justifying the shared understandings to the third investigator (SW) which resulted in further, minor, refinements. Given that one of the authors (VL) is the academic co-ordinator of the PPD theme, reflections and dialogue about the potential for bias and attempts to minimise any effects, were a frequent and integral component of the research discussions.

The framework method⁴⁵ was used throughout our interpretive practice to construct a set of matrices that allowed us to consolidate a view of the thematic elements and their association with the original interview and survey data. The adoption of this approach assisted in the promotion of a methodological and epistemic reflexivity⁴⁶ because connections between the data and related themes could be explicitly articulated. The methodological transparency facilitated an ongoing awareness of the relationships between the data, the thematic elements emerging from the interpretation of the data and the aims and objectives of the research.

Analysis of the foundational PPD curriculum revealed a contradiction between the espoused and the realised value of PPD in the medical curriculum. From an organisational perspective there was incongruity between the rhetoric of support for student professionalism (the rules and norms domain of AT), and the resources allocated to develop and promote the PPD theme. The curriculum theme lacked academic leadership: no individual had responsibility for curriculum evaluation and renewal, and tutor development (a community deficit). The PPD tutors were, and continue to be, casually employed and this represents a trend in the Australian higher education sector.⁴⁷ This employment status, however, establishes a division of labour which did not empower tutors to instigate curriculum change in response to pedagogical problems.

There were further tensions within the foundational PPD curriculum structure. The learning goals and overarching aims were difficult to elucidate from curriculum documents and not clearly articulated to either students or teachers. Moreover, the curriculum was not well supported by scholarly resources, which possibly established the notion that PPD was just common sense. Addressing low level cognitive abilities of knowledge recall and superficial conceptual understanding, assessment reinforced this notion. The messages were clear; the School was uncertain about the outcomes of learning PPD. Students learn well from the hidden and the formal curriculum. PPD was ‘soft’ and ‘useless’.

To address the sources of tension in the learning environment we focused on three overarching educational principles.

   •   Educational leadership is vital for staff development, curriculum development and advocacy of a contested curriculum.^48,49

   •   Learning outcomes should target high level capabilities to achieve professional development and be clearly communicated to students and teachers.^{50, 51}

   •   Alignment between learning objectives, curriculum content, assessment and pedagogical theory is needed to support students to achieve high level outcomes.^50-52

Responding to the pressing need for curriculum reform and addressing the first principle, the School appointed a member of the Medical Education Unit to assume leadership of the PPD Theme (one of the authors, VL). The curriculum reform then commenced with an extensive process of education of, and consultation with, members of the School to renew the pedagogical outcomes for the PPD theme. Accordingly, the object of PPD learning has been reconceptualised in terms of personal growth and patient-centred professional identity formation⁵³ which encompasses intra-personal, interpersonal and sociocultural dimensions. Targeting Tools, as mediators of learning in the AT model, the curriculum content, learning objectives and instructional design were changed to align with the renewed outcomes.

The curriculum content was revised to focus on key philosophical, moral, ethical, legal, socio-cultural and political issues relevant to the formation of a patient-centred professional identity.⁵⁴ Topics include end of life care, the law and duty of care, ethical responsibilities of the medical profession to asylum seekers, gender and race in medical practice and research, anatomy and objectification of the body, and, stigma and mental illness. Each topic is supported by academic literature,⁵⁵ resources from the humanities; film, television, poetry, art, literature, and/or media resources.^56-58 Complex learning objectives addressing high level cognitive, affective behavioural and metacognitive domains were developed to demonstrate the connections between the curriculum content and learning processes to the overarching PPD aim of professional identity formation.

Principles from CoP and Transformational Learning Theory were used to guide instructional design. Didactic lectures and informal tutorials were replaced with structured small group collaborative learning facilitated by tutors with expertise and commitment to the biopsychosocial model of healthcare⁵⁹ and students’ personal development. Both CoP and transformative learning theories advocate for a classroom structure that facilitates positive collaborative learning relationships between students and teacher/s to encourage student development. In the collaborative classroom students are encouraged to question and monitor each other’s’ work and to co-construct group goals, standards and values so that they take on increasing ownership of inquiry.^{27, 33}

To promote enculturation into the medical profession, we utilised scenarios and developed tasks that would illuminate the cultural values and standards expected of healthcare professionals. However, we also presented ethical and moral dilemmas, alternative perspectives to the biomedical approach and social and political issues that required personal reflection and critical thinking and dialogue, to foster perspective change.³² Moreover, medicine was presented as a social, cultural, political and historical practice.⁶⁰ We wanted students to appreciate that medical professionalism is dynamic and evolves. As the next generation of doctors, not only are they shaped by the profession, but the profession will also be shaped by them.

Facilitating transformative learning demands dedicated, highly skilled teachers who are able to tolerate ambiguity and encourage constructive dialogue on highly sensitive issues.³³ To role model learning and personal change to their students, teachers must be reflexive about their teaching.^32,34 They are also required to promote a transition of labour between themselves and students which requires a sensitivity to, and ability to manage, the dynamics of power within the group.³⁵

Hence, staff selection and development was a high priority for PPD curriculum reform.^61,62 Regular tutor meetings and workshops were scheduled to facilitate the formation of a PPD community of practice for support, collegiality and learning.^63,64 The tutors were also provided with a handbook providing strategies for each tutorial topic to encourage critical reflection of students’ current meaning structures and worldviews and exploration of alternative perspectives.⁶⁵

Potentially, assessment can undermine other attempts to move towards a more student centred pedagogy.⁶⁶ Previously conducted as end of semester summative multiple choice or short answer questions, we changed the mode of assessment and moved to a progressive, formative approach to align with the developmental outcomes of the PPD Theme.⁶⁷ A variety of individual and group based assessment formats were employed such as reflective journaling, research essays, class presentations and creative responses, and students were offered a choice of topics and assessment modes. A criterion-based, non-graded assessment system was adopted and students provided with opportunities for remediation and mentoring if they were not satisfactory in any assessment task.

The change towards a longitudinal and formative approach to assessment was not supported by the current technological learning management system (LMS) of the university. The LMS tool does not allow students to maintain a continuous record of their work and nor does it facilitate the provision of timely feedback as students work develops. Records of student learning are static finalised products to be uploaded for assessment, not dynamic documents which can be changed upon further reflection or in response to feedback provided by teachers and peers.

Our search for an alternative platform serendipitously coincided with the university’s decision to adopt, in trial mode, a new edition of an e-portfolio product. The e-portfolio platform contained functionalities which enabled submission of regular reflections on experience and previous work, and collaborations on developing work with peers and tutors, thereby promoting the type of formative educational experience that was aimed for. Introduction of new technology can be highly challenging for tutors,⁶⁸ hence we provided them with intensive instruction. In turn, the tutors were expected to assist students during an introductory tutorial and provide ongoing support.

Following two complete academic years of the renewed PPD curriculum a second evaluative phase was undertaken. Written qualitative feedback was sought from students about their learning in PPD and tutors discussed their experiences of facilitating student learning in focus groups. The student and tutor data were analysed separately. The themes which emerged from analysis of both data sets revealed a concordance which was unexpected given the different positions, roles and goals of tutors and students. We undertook a second level of analysis and compared and contrasted the data between the two groups. This process confirmed shared perceptions and common themes about learning and assessment in PPD and hence will be presented together (Table 2).

There was one theme however, that was specific to the tutors’ experience as staff members of the SoM, ‘Collegiality and Belonging’. Over the two years of working together to build and deliver the new curriculum the tutors reported the development of a strong sense of community and common purpose. As casual employees of the SoM, they considered that the PPD coordinator should have the major responsibility for curriculum development. However, because their contributions were sought, valued and employed in the curriculum reform, they felt a sense of ownership and pride in the renewed PPD curriculum.

“…it’s been good for my own personal growth and learning- my development too because when I teach I learn too. When I come up with ideas which I share here and that’s been valued and encourages me to come and contribute the way I have been and  I definitely feel part of the SoM” (Tutor)

They also reported a strong sense of belonging to the SoM which was important for staff involved in the delivery of a contested part of the curriculum. Moreover, even though tutors felt that they still had to “sell” the value of PPD to students, this had become a much easier task with the new curriculum. Increased student engagement combined with their own greater involvement with the SoM worked to legitimise their practice as teachers of PPD and increase their sense of achievement.

“…As a participant in the provision of PPD experiences, it is a course that I feel immensely proud of” (Tutor)

Ninety-five percent of participating students said that PPD contributed positively to their learning and professional development, however this may be an overestimate, given the 11% non-participation rate in the study. Students’ reflections about the way in which PPD contributes to their development as a health care professional converged on two principal themes ‘Developing a philosophy of medicine’ and ‘Becoming an ethical doctor’. The student themes corresponded with the tutors aims for student learning and with the overarching aims of the PPD theme.

The theme ‘Developing a philosophy of medicine’, encompasses students’ burgeoning understanding that medicine was more than a science. Opportunities to focus on the patient’s experience of illness, (which included interviews with patients in the community and narrative writing from the patient’s perspective) helped students to cultivate a biopsychosocial understanding of medicine.

“The PPD tutorials and assessments have given me a very good understanding of the social issues in medicine and the concept of 'patient-centred care'. I feel that PPD will make me a more aware medical student and doctor - allowing me to work with others to treat patients as a whole.” (Year 1 student)

“It introduces early other aspects of medicine, rather than purely science. It helps adaptation into the role of practitioner by setting clear expectations on ethics and professionalism which can be practiced in a clinical setting.” (Year 1 student)

Tutorial topics which addressed the socio-political dimensions of medicine promoted a broader perspective on the roles of the doctor. Second year students are required to write a group position paper about the health and wellbeing of refugee and asylum seekers in Australia. Many students said this activity, and other similar learning experiences, gave them a new understanding of the relationship between medicine and politics and the role of advocacy in professional practice.

“The PPD curriculum provides students with numerous topics related to current issues about medical systems, political and social problems which are essential to construct the fundamentals for a health professional.” (Year 2 student)

“PPD helps me develop into someone who has a better understanding of the broader, at times, controversial issues that surround the medical profession. It allows me to transcend the barriers of science into the clinical realm to better understand and connect with my future patients.”  (Year 1 student)

The theme, ‘Becoming an ethical doctor,’ -focused on students’ and tutors’ perceptions of how PPD assisted the development of a professional identity. PPD provided opportunities to explore the qualities important for ethical and patient-centred practice and imagine professional identities which encompassed more than technical competence. PPD also guided, and stimulated reflection on, appropriate ethical behaviour in the clinical environment. Students appreciated reflecting on how they and others were currently behaving with patients and each other, and also envisaging how to respond in an ethical way as their clinical responsibilities developed. Becoming an ethical practitioner was becoming part of their lexicon for which PPD received credit.

“Always an opportunity for insight and reflection that is often neglected with university studies.” (Year 2 student)

“Provides guidance and helps us nurture the skills to develop morally and ethically for a vocation in medicine.”  (Year 2 student)

“It allows us to contemplate who we are and sort out what sort of doctor we want to become.” (Year 1 student)

The themes which capture student learning in PPD illustrate that they were experiencing an epistemological shift. The ‘soft’ curriculum, previously dismissed as irrelevant to professional development, facilitated a change in perspective about the epistemological foundation of medicine, taking them beyond a technical rationalist model of medical practice. Together with the development of a philosophy of medicine, students imagined becoming a particular sort of doctor; preparations and beginnings of an identity change.

Students and tutors emphasised the importance of the unique learning environment of PPD tutorials for nurturing personal development. The shared theme, ‘Learning through discussion, critical thinking and reflection in a safe environment’ was highly representative of student and tutor reflections on the dynamics of the PPD learning environment. Expressing personal views, being challenged and engaging with alternative perspectives was particularly valued by students. Peer discussions were especially important for learning, but students also cited engagement with the scholarly literature and resources from the humanities as critical triggers for perspectival change.

“Reading and discussion during tutorials contribute to my understanding since many people's opinions are being shared and discussed. Informal environment encourage discussion.” (Year 2 student)

“PPD gives an opportunity for thorough in depth discussions about important issues in medical practice that are not easily openly discussed without a platform for it, like PPD. This promotes an awareness and sensitivity to what it means to assume the professional identity.” (Year 2 student)

“Multi-faceted learning that gives an insight from other perspectives, specially the patient’s which is of utmost importance as they are who we will be interacting with and it is for their benefit that we will work for.” (Year 2 student)

Voicing personal opinions, engaging in value-laden discussions and learning about oneself and others requires a safe, supportive and nonjudgmental space which PPD provides. Students recognised this culture as fundamental to the ethos of PPD and vital for their engagement and learning. Correspondingly, tutors considered the establishment of this trusting environment to be one of the most critical components of their teaching responsibilities.

“PPD is a place where people feel safe it’s re-contextualising their learning-it’s a catalyst that opens up honesty. It gives them a chance to reflect. If you had a debriefing in a … context the venom might come out. But in PPD it’s safe.” (Tutor)

Students and tutors identified both positive (Assessment promotes learning) and negative aspects of the assessment reforms (The e-portfolio undermines learning). Given that the e-portfolio provided the technological and pedagogical structure for assessment, these two themes seemed contradictory. AT was used to analyse the tensions created by the introduction of the new technology and understand how both students and tutors could, notwithstanding the problems of the e-portfolio, claim that assessment promoted learning (Figure 1).

Technology must be intuitive and easy to use, even for the currently technological savvy generation of students,⁶⁹ and institutional support is  critical for the successful implementation of educational designs that incorporate the use of new technology.⁷⁰ Early after introduction of the e-portfolio it became apparent that the accompanying institutional technological support (community) was insufficient to address the significant technical issues (of the tool) that arose. The burden of helping the students with the new technology was consequently shifted on to tutors who, despite intensive training in the use of the e-portfolio, struggled to fulfil this role (tension 3). Both students and tutors found the interface of the e-portfolio technology complicated, unintuitive and difficult to use. Learning how to navigate the interface took up valuable tutorial time, disrupting rather than supporting PPD learning, leading to frustration, stress and feelings of ’time wasting’ (tension 1).

Despite instigating several strategies to increase support to students and tutors (workshops, online resources, one on one support), students and tutors continued to experience difficulty. In response, students proactively selected alternative technological tools to facilitate their group learning (such as Facebook and email). The assessment rules required collaborative engagement via the e-portfolio (tension 2). However, the relatively flat division of labour within the PPD learning environment allowed students to successfully negotiate the use of these alternate tools with the teaching and design staff, who responded by relaxing the rules to facilitate resolution of this tension in the learning environment.

Consequently students used the e-portfolio as a drop-box or repository for the products of learning rather than as a medium for the development of progressive knowledge construction and learning. In turn, tutors did not have access to the ideas that were being developed by students out of class time and were therefore not in a position to offer formative feedback through the e-portfolio as planned.

“The e-portfolio does not add anything to sharing information, collaborating ideas, and communicating. Students already have an efficient and much simpler means of doing so.” (Year 2 student)

“We don’t want it to end up about just using the e-portfolio and submitting and assessment. We want it still centred around their professional development. You don’t want the tutorial time eaten up by the logistics of using a system and all of that.” (Tutor)

If this pedagogical strategy for tying assessment to learning had failed, how could students and tutors claim that assessment promotes learning? Eighty-five percent of student respondents said that assessment enhanced their learning by encouraging a deeper exploration of topics discussed in class, stimulating personal reflection and providing both the choice to pursue topics of individual interest and opportunities for creative expression. Moreover, the progressive and more formative approach to assessment was appreciated, because it supported the developmental emphasis of the PPD theme. 

“The essay discussion based activities provide an open forum to express ideas about issues of particular interest to us, thereby creating a self-motivation to learn.” (Year 2 student)

“Solidifies own thoughts into a concrete piece of art/writing. This encouraged me to structure and organise my ideas discovering other truths along the way.” (Year 1 student)

Despite the contradictions introduced into the learning environment by the e-portfolio, interactions between the community, the tools and the division of labour, enabled students and tutors to maintain a focus on the object and outcomes for PPD. In a supportive and flexible learning community students were empowered to overcome obstacles to their learning by negotiating alternative pathways. Moreover, students and tutors reminded us that the most valuable learning was not mediated by the latest technological tool, but rather by discursive engagement with others during tutorials.

“…The profound benefits are the engagement in class – by, let’s say we are the students, sharing our learning ... getting consensus, affirming some of the things that we’ve reflected on, opening up new perspectives, that’s the benefit….. That’s just putting the cards on the table so you can play the game. And the game is in the tutorial.”  (Tutor)

Integrating feedback into the structure of the learning activity, rather than treating it as a separate item, enhances its value in the context of the formative development of students.

An important limitation of this study was the omission of a formal systematic inquiry into the perspectives of the key academic staff of the School who were not directly involved in PPD teaching. We are, therefore, circumspect about drawing firm conclusions about the nature of the PPD discourse in the wider community of the School. We did however, have frequent meetings and discussions with the School academics, particularly during the process of negotiating the renewal of the PPD outcomes. Moreover, as members of the relevant committees, we can claim that PPD in the preclinical years is no longer a subject of concern as another accreditation visit looms. A further limitation to this study was the 11% rate of student non-participation. There may have been a disproportionate number of students amongst this group who did not value the curriculum reforms; hence we may have overestimated its positive impact. Furthermore, our results are highly contextual and relevance to other educational environments will need to be interpreted accordingly.

The authors would like to acknowledge the contributions of all the PPD tutors and the medical students who took part in this study. We would also like to thank all our colleagues from the School of Medicine who either contributed to the curriculum development and administration of the PPD theme, or provided their support.

One of the authors (VL) is the academic coordinator of the PPD theme and therefore may be predisposed to bias in terms of interpretation of students and tutors responses to the curriculum reforms. The other authors (GM and SW) are educators from the Medical Education Unit who have no academic responsibility for the PPD theme. We held weekly research meetings which involved frequent reflections on the relationship between our academic positions and perspectives and values as investigators and our relationships with the research participants and the interpretations and the stages of the research project.